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Flashcards in Upper GI - Oxford Handbook MCQs Deck (34):
1

A 28-year old woman has dysphagia and low retrosternal ''sticking'' and an occasional sensation of choking. A video barium swallow shows an apperance of a ''bird-beak' esophagus. Which is the single most likely diagnosis? 

A. Achalasia

B. Carcinoma of the esophagus 

C. Diffuse esophageal spasm 

D. Foreign body ingestion 

E. Reflux esophagitis 

A - Achalasia 

  • Defined as a failure of relaxation of the distal esophageal musculature associated with degeneration of the myenteric plexus is among the common cause of dysphagia in the younger population. 
  • The radiological appearance of a ''bird-beak'' esophagus is characteristic of achalasia with a single, smooth, distal esophageal abnormality where the lumen tapers sharply to a fine point. 
  • The lack of mucosal irregularity makes a tumour very unlikely and diffuse spasm gives variable multiple level abnormality. 
  • A reflux stricture would be very rare at her age and would normally be preceded by a long history of reflux symptoms rather than just dysphagia. 

2

A junior medical student asks you about the principal differences of
macroscopic appearances and functions of the proximal jejunum
and distal ileum. Which is the single correct statement comparing the
features of each? 


A Compared to the ileum, the jejunum: absorbs less vitamin B6, is thinner
walled, and secretes more fluid during digestion


B Compared to the ileum, the jejunum: absorbs more vitamin B6,
secretes less fluid during digestion, and appears redder in colour


C Compared to the ileum, the jejunum: is thicker walled, possesses less
prominent lymphoid tissue, and secretes more fluid during digestion


D Compared to the ileum, the jejunum: possesses less prominent lymphoid
tissue, paler and appears blue in colour, absorbs less vitamin B6


E Compared to the ileum, the jejunum: possesses more prominent lymphoid
tissue, appears paler blue in colour, and secretes less fluid during
digestion

C - Compared to the ileum, the jejunum: is thicker walled, possesses less
prominent lymphoid tissue, and secretes more fluid during digestion

  • The jejunum is generally:
    • thick walled 
    • darker red and more purple in colour 
    • with prominent plicae circulares 
    • a predominantly digestive organ producing the majority of digestive fluid from the small bowel and performing the majority of the absorption for both main nutritional elements and micronutrients. 
  • The ileum tends to be:
    • paler
    • bluer 
    • thinner walled 
    • with thinner plicae circulares 
    • with prominent lymphoid follicles. 
  • The only vitamin absorbed predominantly in the distal ileum is B12. 
  • Practically, injuries to or loss of the jejunum results in relatively more loss of digestive and absorptive capacity than of the distal ileum but loss of the distal ileum leaves the jejunum which is a mainly secretory organ meaning that fluid loss is more likely to be a problem. 

3

A 72-year-old man has had a sensation of retrosternal burning that
is worse at night and after meals for the last 4 months. It partially
responds to ‘over the counter’ antacid treatment. Which is the single
most appropriate initial diagnostic investigation? 


A Barium meal
B Barium swallow
C CT scan thorax
D OGD
E 24h pH studies

D - OGD

  • This man most likely has gastro-esophageal reflux disease. 
  • The differential diagnosis includes:
    • esophageal or gastric malignancy 
    • functional disesae 
    • peptic ulcer disease 
  • First line investigation should be direct visualization of the esophagus and stomach. 
  • A barium swallow would exclude tumours or stricturing but would not assess the mucosal integrity so well or allow biopsies to be taken. 
  • 24-hour pH studies may be useful to evaluate the severity or timing of GERD but are not useful for diagnosis

4

A 64-year-old woman undergoes an oesophagogastroduodenoscopy
(OGD) to investigate difficulties and discomfort with swallowing.
A tumour is found in the distal oesophagus. Biopsies are taken.
Which is the single most likely histological diagnosis? 


A Adenocarcinoma
B GI stromal tumour
C Lipoma
D Rhabdomyosarcoma
E Squamous cell carcinoma

A - Adenocarcinoma 

  • Adenocarcinoma is by far the commonest malignancy of the esophagus and typically occursi n the lower half although it is now the most common diagnosis for a malignant tumour below the cricopharyngeus muscle having exceeded squamous carcinoma in incidence. 
  • Lipomas rarely occur in the esophagus since there is little submucosal tissue (unlike the small bowel and colon where they are not uncommon) 
  • Similarly, the amount and distribution of autonomic nervous tissue means that GI stromal tumours are much more common in the stomach than the esophagus. 
  • The esophagus is the commonest location in the GI tract for rhabdomyosarcoma but it is still a very rare tumour. 

5

A 50-year-old man has a 15-pack-year history of smoking and
undergoes an OGD. There is a duodenal ulcer present. Gastric
biopsies are taken and undergo a rapid urease test. Which single organism
is most likely to be identified? 


A Clostridium difficile
B Escherichia coli
C Enterobacter
D Helicobacter pylori
E Staphylococcus aureus

D - H.pylori 

  • Duodenal ulceration is frequently associated with H.pylori. 
  • The causation is due to increased acid production from the antrum of the stomach,  possibly due to suppression in the gastric crypts due to penetration of the gastic mucus layer by certain strains of the organism which results in chronic mucosal gastritis. 
  • The presence of the organism can be identified in gastric biopsies with a rapid urease test which is more sensitive than microscopic examination of the biopsies for the presence of the organisms 
  • C.difficile can be found in the stomach and is not always pathological but when so causes diarrhoea rather than duodenal ulceration. 

6

A 79-year-old man has an incidental finding of a haemoglobin of
9.1g/dL and mean corpuscular volume of 72fL with mild postprandial
epigastric pain. Which is the single most appropriate first-line
investigation? 


A Barium meal
B CT scan thorax
C MRI upper abdomen
D OGD
E Ultrasound scan upper abdomen

D - OGD

  • Although there is no ferritin given, the microcytic nature of the anaemia suggests an iron deficiency most likely due to occult blood loss. 
  • In a man of his age, the most likely sites for pathology which might cause this are:
    • proximal colon 
    • the stomach 
    • the duodenum 
    • the kidney 
  • The usual investigation strategy is for combined (sequential) OGD and colonscopy with an abdominopelvic CT scan if these first line investigations are negative. 

7

A 67-year-old man is found to have adenocarcinoma of the stomach.
Which single blood group is this pathology associated with? 


A A
B AB
C B
D O
E None of these

A - A

Gastric adenocarcinoma is associated with blood group A. Other risk factors include:

  • a high smoking exposure history 
  • a diet rich in nitrosamines (e.g. raw fish consumption) 
  • chronic atrophic gastritis 

8

A 69-year-old woman with rheumatoid arthritis has had 24h of
epigastric pain, abdominal tenderness, and fever. She takes regular
ibuprofen and has recently been taking oral steroids. An erect chest
X-ray is taken in the emergency department (showing subdiaphragmatic free air) 

Which is the single most likely diagnosis? 


A Acute pancreatitis
B Bleeding duodenal ulcer
C Incarcerated hiatus hernia
D Perforated peptic ulcer
E Right lower lobe pneumonia

D - Perforated peptic ulcer 

  • In an erect chest X-ray there would be a thin sliver of free gas under the right hemidiaphragm over the liver. 
    • This would be too small to be a bowel loop and there are no features of change in the lung parenchyma making a liner collapse due to chest infection unlikely. 
    • The CXR features are of a perforated viscus. 
  • With epigastric pain and a history of taking steroids and NSAIDs the most likely cause is a perforated peptic ulcer. 
  • Acute pancreatitis may give rise to all of the same clinical features but in the absence of extreme complications, visceral perforation is unlikely. 
  • Bleeding duodenal ulcer is also a well-recognized complication of NSAID and steroid medication but a history of bleeding and a degree of hemodynamic instability would be expected.
  • Right lower lobe pneumonia is a notorious mimic of intra-abdominal pathology with symptoms and signs which can be exclusively abdominal at presentation. 
  • There is no evidence of radiological features of lower lobe change but that does not exclude the condition, however the presence of free air makes the diagnosis. 

9

A 79-year-old man has been having frequent dark black/bloody
semi-liquid and foul smelling stools over the last 24h associated
with vague generalized abdominal pain and bloating. His haemoglobin is
12.5g/dL, white blood cell count 11 × 109/L, and serum urea 18mmol/L.
Which is the single most likely diagnosis? 


A Angiodysplasia of the stomach
B Bleeding duodenal ulcer
C Clostridium difficile colitis
D Colonic carcinoma
E Gastroenteritis

B - Bleeding duodenal ulcer

  • The history is of melaena rather than dark colonic bleeding and the raised urea suggests that there has been absorption of protein (in the form of haemoglobin) from the small intestine meaning that the bleeding is likely to be from the duodenum or above. 
  • Gastroenteritis rarely causes frank bleeding and a duodenal peptic ulcer is much more common than gastric angiodysplasia. 

10

An 83-year-old man is admitted with acute onset of severe
epigastric pain and has ‘board-like’ rigidity of the upper abdomen.
His temperature is 37.4°C, pulse rate 124bpm, blood pressure
104/75mmHg. A working diagnosis of visceral perforation is made and
investigations planned. Which is the single most appropriate fluid prescription
to administer? 


A IV Hartmann’s solution 500mL, over 2h
B IV O-negative blood 2 units, run in
C IV sodium bicarbonate 0.13% 500mL, over 2h
D IV sodium chloride 0.9% 100mL, over 2h
E IV whole cross-matched blood 2 units, over 4h

A - IV Harmann's solution 500 mL, over 2 hours. 

  • This is a classic presentation and the tachycardia and hypotension are usually due to autonomic instability rather than absolute hypovolaemia
  • The priority is to re-establish the circulating volume rapidly and this is best done with a bolus of isotonic solution 
  • Bleeding is rarely associated with a visceral perforation and thus blood of either type is not indicated. 
  • It is also slow to administer making it inappropriate as a direct volume restorative. 
  • Neither the bicarbonate nor the 0/18% saline are isotonic thus Hartmann's solution or 0.9% saline would be appropriate. 
  • In fact, the exact fluid administered is less important than the rate so the 100 mL of saline is inadequate. 

11

A 13-year-old adolescent girl has had 2 days of increasing right
iliac fossa and lower abdominal pain with tenderness and guarding.
Her temperature is 37.8°C, pulse is 92bpm. A provisional diagnosis
of acute appendicitis is made and a laparoscopic appendicectomy
planned. Which is the single most appropriate investigation prior to the
procedure? 


A Abdominal X-ray
B Chest X-ray
C CT scan abdomen and pelvis
D Pregnancy test
E Transabdominal pelvic ultrasound scan

D - Pregnancy test 

  • The diagnosis of acute appendicitis has been made clinically
  • CXR, AXR and pelvic ultrasound cannot reliably make or exclude the diagnosis and will not alter the decision to proceed. 
  • CT scanning is contraindicated because of her age
  • Ovarian disease is unlikely and would be best identified on transvaginal ultrasound scan which is probably not indicated in a girl of this age. 
  • Once the diagnosis has been made, diagnostic laparoscopy with a view to appendicectomy is the procedure of choice
  • The only diagnosis which would affect this decision is the establishment of pregnancy:
    • thus a pregnancy test is mandatory before proceeding with surgery even at this relatively young age. 

12

A 6-week-old boy is brought to hospital with projectile and persistent
vomiting. Weight gain has been poor. The child appears
listless and quiet. A lump is palpable in the upper abdomen. Pulse is
100bpm, serum electrolytes are sodium 132mmol/L and potassium
3.2mmol/L. A provisional diagnosis of pyloric stenosis is made. Which is
the single most appropriate initial intervention? 


A Administration of IV bicarbonate 8.4% solution (weight adjusted)
B Administration of IV 0.9% sodium chloride (weight adjusted)
C Administration of a test feed
D Commencing nil by mouth
E Insertion of a nasogastric tube

B - Administration of IV 0.9% sodium chloride (weight adjusted) 

  • Hypertrophy of the pyloris can cause a gastric outlet obstruction leading to persistent projectile vomiting
  • This usually becomes apparent in the first 2 months of life
  • The vomit is high in potassium and chloride and the child may develop hypochloraemic alkalosis 
  • A nasogastric tube will be very difficult to inset and will do nothing to correct any underlying electrolyte imbalances, neither will making the child nil by mouth. 
  • A test feed is helpful for diagnosis but the diagnosis may be assumed and restoration of potential physiological upset is a priority. 
  • The most likely problem is alkalosis so bicarbonate is contraindicated particularly in hypertonic concentrations of 8.4%
  • Isotonic (.9%) saline is appropriate as a first step since with provision of sodium and potassium ions, renal function will usually correct the acid-base imbalances automatically. 

13

An 8-month-old boy is described by his mother as having
3 days of intermittent severe distress and restlessness and the
recent passage of bloody motions and mucus-like material. There has
been some vomiting and the abdomen is mildly distended and tender to
examination. Which is the single most likely diagnosis? 


A Gastroenteritis
B Hirschsprung’s disease
C Intussusception (ileocaecal)
D Pyloric stenosis
E Small bowel volvulus

C - Intussusception 

  • Vomiting, infantile distress and abdominal bloating are non-specific features which may apply to most of these diagnoses
  • The age of 8 months is too late for a likely presentation of Hirschsprung's disease and the abnormal stools are not typical at all for pyloric stenosis. 
  • Gastroenteritis may produce blood diarrhoea in severe cases but the episodic nature of the symptoms suggests intestinal colic which is most likely from an obstructive process. 
  • Small bowel volvulus will not cause bloody stools thus intussusception is most likely 
  • It typically occurs between the ages of 3 and 10 months. 
  • Pain, features of bowel obstruction and the passage of 'redcurrant jelly' stool are typical. 

14

A 27-year-old woman has had 4 days of gradually increasing,
diffuse lower abdominal pain and 6h of acute severe worsening
of the pain. Her abdomen is tender with guarding in the lower half.
Her temperate is 37.2°C, pulse 104bpm, blood pressure 104/56mmHg,
and capillary refill approximately 6sec. Which is the single most likely
diagnosis? 


A Acute tubo-ovarian abscess
B Endometriosis
C Perforated diverticulitis
D Ruptured ectopic pregnancy
E Torted ovarian cyst

D - Ruptured ectopic pregnancy 

  • The clinical findings clearly indicate that the patient shows signs of hypovolaemic shock which is inconsistent with a torted cyst or endometriosis. 
  • This is most likely to be due to blood loss or acute severe sepsis.
  • Both tubo-ovarian abscess and diverticulitis may rupture acutely with a rapid deterioration but the diffuse nature of symptoms and delayed capillary refill are most consistent with blood loss rather than sepsis making ruptured ectopic pregnancy the most likely cause. 

15

A 34 year old woman has abdominal discomfort and loose stools after food with a weight loss of 5kg over 12 months and has developed poor skin and hair texture. She has haemoglobin of 8.3g/dL and ferritin of 7mg/dL. What investigation is appropriate: 

A Abdominal ultrasound scan
B Barium enema (double contrast)
C Capsular endoscopy
D Colonoscopy
E CT colonography (‘CT colonoscopy’)
F CT scan of the abdomen
G Endoscopic ultrasound scan
H OGD with duodenal biopsy
I OGD with gastric biopsy
J OGD with oesophageal biopsy
K Small bowel follow through

H - OGD with duodenal biopsy 

  • This woman has iron deficiency anaemia and discomfort after eating suggestive of coeliac disease. 
  • Established coeliac disease gives rise to malabsorption of both key nutrients (as suggested by weight loss) and micronutrients (as suggested by hair and skin changes) 
  • Whilst serum tissue transglutaminase testing is routine, biopsies from the distal duodenum are required to confirm the diagnosis of coeliac disease (villous atrophy with intra-epithelial lymphocytes) 

16

A 63 yer old man is under surveillance for Barrett's metaplasia. What investigation is appropriate:

A Abdominal ultrasound scan
B Barium enema (double contrast)
C Capsular endoscopy
D Colonoscopy
E CT colonography (‘CT colonoscopy’)
F CT scan of the abdomen
G Endoscopic ultrasound scan
H OGD with duodenal biopsy
I OGD with gastric biopsy
J OGD with oesophageal biopsy
K Small bowel follow through

J - OGD with esophageal biopsy 

  • Barrett's metaplasia affects the lower part of the esophagus and is the transformation of squamous to glandular epithelium in the anatomical esopahgus. 
  • Surveillance for dysplastic changes involves biopsies from this region to detect potentially premalignant changes of high grade dysplasia. 

17

A 24 year old man has progressive, intermittent right iliac fossa pain with variable loose stools and weight loss of 10 kg for 2 years. What investigation is most appropriate? 

A Abdominal ultrasound scan
B Barium enema (double contrast)
C Capsular endoscopy
D Colonoscopy
E CT colonography (‘CT colonoscopy’)
F CT scan of the abdomen
G Endoscopic ultrasound scan
H OGD with duodenal biopsy
I OGD with gastric biopsy
J OGD with oesophageal biopsy
K Small bowel follow through

D - Colonscopy 

  • This man has features of Crohn's disease of the terminal ileum. 
  • A small bowel follow through might give information about the terminal ileum but it is not usually diagnostic and is best reserved for assessment of complications of an established diagnosis especially of more proximal disease. 
  • Similarly, capsule endoscopy is usually used for diagnosis where CT and colonscopy have not provided clear evidence. 
  • Colonoscopy with terminal ileum intubation is the first-line investigation to attempt to acheive a biopsy proven diagnosis. 

18

A 84 year old woman with severe chronic obstructive pulmonary disease and chronic renal impairment on long term oral steroids. She has a palpable right iliac fossa mass. Her haemoglobin is 7.7 and ferritin of 9. What is the most appropriate investigation? 

 

A Abdominal ultrasound scan
B Barium enema (double contrast)
C Capsular endoscopy
D Colonoscopy
E CT colonography (‘CT colonoscopy’)
F CT scan of the abdomen
G Endoscopic ultrasound scan
H OGD with duodenal biopsy
I OGD with gastric biopsy
J OGD with oesophageal biopsy
K Small bowel follow through

E - CT colonography (CT colonscopy) 

  • Iron deficiency anaemia is usually investigated with an OGD and colonscopy
  • In this woman, the right iliac fossa findings strongly suggest a colonic neoplasm but colonscopy is relatively contraindicated by her severe chronic obstructive pulmonary disease and renal impairment 
  • Double contrast barium enema would assess the right colon and a plain abdominal CT scan would give some information about a right iliac fossa mass but the combination of CT scanning with colonic imaging by preparation and air colonography (sometimes called CT colonoscopy) is more accurate in assessing the right iliac fossa/possible caecal pathology and gives the same staging information as plain abdominal CT scanning. 

19

A 63 year old man admitted with upper abdominal pain and melaena for 24 hours. His heart rate is 108 bpm and blood pressure is 98/45mmHg. What is the single most appropriate investigation? 

A Abdominal ultrasound scan
B Barium enema (double contrast)
C Capsular endoscopy
D Colonoscopy
E CT colonography (‘CT colonoscopy’)
F CT scan of the abdomen
G Endoscopic ultrasound scan
H OGD with duodenal biopsy
I OGD with gastric biopsy
J OGD with oesophageal biopsy
K Small bowel follow through

I - OGD with gastric biopsy 

  • This main is likely to have an upper GI bleed with a peptic ulcer, gastritis or undiagnosed varices among the most likely diagnoses. 
  • An OGD is required to make the diagnosis and haemostatic therapy may be used to stop the bleeding. 
  • Biopsies of esophageal disease or an active duodenal ulcer are usually contraindicated in acute bleeding. 
  • Gastric biopsies may be of use if a gastric carcinoma is suspected. 

20

A 27 year old woman has severel years of progressive dysphagia and a 'bird's beak' appearance on barium swallow. Balloon dilatation has failed and she requires surery. What is the single most appropriate operation required? 

A Anti-reflux fundoplication
B Cardiomyotomy (‘Heller’s operation’)
C Duodenotomy and repair
D Gastrojejunal bypass
E Hepaticojejunostomy
F Oesophagectomy
G Pancreaticoduodenectomy
H Partial gastrectomy
I Total gastrectomy

B - Cardiomyotomy (Heller's operation)

  • The diagnosis is achalasia - the sex, age and presentation are typical. 
  • Balloon dilatation can be used in other situations but it is most commonly used in achalasia. 
  • Heller's cardiomyotomy is performed (usually laparoscopically) to divide the distal esophageal muscle fibres to reduce the spasm and relieve the dysphagia 

21

A 47 year old man has a longstanding gastro-esophageal reflux disease and has severe persistent and debilitating symptoms despite maximal medical therapy. What operation is most appropriate?

A Anti-reflux fundoplication
B Cardiomyotomy (‘Heller’s operation’)
C Duodenotomy and repair
D Gastrojejunal bypass
E Hepaticojejunostomy
F Oesophagectomy
G Pancreaticoduodenectomy
H Partial gastrectomy
I Total gastrectomy

A - Anti-reflux fundoplication 

  • Surgical intervention is indicated in patients with severe resistant symptoms or those with complications despite treatment. 
  • The procedure of choice is an anti-reflux procedure designed to increase the dynamic tone around the lower esophagus and gastro-esophageal junction. 
  • Various procedures to wrap the proximal stomach around the gastro-esophageal junction have been described but commonest of these is the Nissen fundoplication 

22

A 52 year old man has ongoing melaena in hospital. He has a proven proximal duodenal ulcer and has continued bleeding despite two episodes of endoscopic treatment. What is the most appropriate operation? 

A Anti-reflux fundoplication
B Cardiomyotomy (‘Heller’s operation’)
C Duodenotomy and repair
D Gastrojejunal bypass
E Hepaticojejunostomy
F Oesophagectomy
G Pancreaticoduodenectomy
H Partial gastrectomy
I Total gastrectomy

C - Duodenotomy and repair 

  • Bleeding from the posterior part of the proximal duodenum is a common site for upper GI bleeding. 
  • Ulcers here are almost always benign but may be life thretening and recurrent bleeding despite endoscopic therapy requires emergency surgery. 
  • Occassionally the duodenum is severely damaged and cannot be repaired necessitating a partial gastrectomy but much more commonly duodenotomy and under running of the bleeding vessel with a suture will control the bleeding vessel. 

23

A 67 year old man with no other medical co-morbidity has a carcinoma of the body of the stomach staged as T2 N0. What is the most appropriate operation required? 

A Anti-reflux fundoplication
B Cardiomyotomy (‘Heller’s operation’)
C Duodenotomy and repair
D Gastrojejunal bypass
E Hepaticojejunostomy
F Oesophagectomy
G Pancreaticoduodenectomy
H Partial gastrectomy
I Total gastrectomy

I - Total gastrectomy 

  • Gastric carcinoma is potentially curable by radical resection provided there is no evidence of metastatic disesae. 
  • This includes anything more than local lymph node disease
  • With a staging of T2 the primary is confined to the stomach and N0 indicates no nodal disease. 
  • Thus palliation, such as bypass, is only indicated for those not fit for resection. 
  • Being in the body of the stomach it is most likely that radical total gastrectomy is required rather than partial gastrectomy. 

24

A 74 year old man with invasive adenocarcinoma of the head of the pancreas involving the superior mesenteric vessels. What is the most appropriate operation required? 

A Anti-reflux fundoplication
B Cardiomyotomy (‘Heller’s operation’)
C Duodenotomy and repair
D Gastrojejunal bypass
E Hepaticojejunostomy
F Oesophagectomy
G Pancreaticoduodenectomy
H Partial gastrectomy
I Total gastrectomy

Gastrojejunal bypass

  • Carcinoma of the pancreas may be amenable to curative surgery depending on location and involvement of local structures. 
  • Tumours of the head may be resectable by pancreaticoduodenectomy but involvement of the major vessels effectively renders the tumour incurable. 
  • Since the tumour is involving the head - the most likely complication is gastric outlet or duodenal obstruction and a gastrojejunal bypass may be necessary to treat it. 
  • Obstruction of the common bile dut may occur but bypasses such as hepaticojejunostomy are rarely necessary with endoscopic and radiological stenting techniques. 

25

A 25 year old man undergoes operation for suspected appendicitis. However, an inflammed Meckel's diverticulum is found and excised. Histopathological examination identifies another pathology within the diverticulum in addition to the inflammation. What is the single most likely diagnosis? 

A Adenocarcinoma
B Chronic intestinal ischaemia
C Diffuse oesophageal spasm
D Gastro-oesophageal reflux disease
E Laceration (traumatic)
F Myocardial infarction
G Neuroendocrine tumour (‘carcinoid type’)
H Peptic ulcer
I Pharyngeal pouch

G - Neuroendocrine tumour (carcinoid type)

  • Meckel's diverticula can be associted with 'peptic' ulceration due to the presence of gastric acid secreting mucosa but the perforation occurs in the normal ileal wall adjacent to the diverticulum. The small bowel is the commonest site of neuroendocrine tumours, the most common of which is a carcinoid tumour and aberrant tissue - such as a Meckel's - which can show a predilection for such tumours. 

26

A 22 year old man with small volume haematemesis following a prolonged episode of vomiting during an evening of binge drinking. What is the most likely diagnosis? 

A Adenocarcinoma
B Chronic intestinal ischaemia
C Diffuse oesophageal spasm
D Gastro-oesophageal reflux disease
E Laceration (traumatic)
F Myocardial infarction
G Neuroendocrine tumour (‘carcinoid type’)
H Peptic ulcer
I Pharyngeal pouch

E - Laceration (traumatic) 

  • Violent vomiting can cause a traumatic laceration in the lining of the esopagus leading to bleeding and haemaetemesis (Mallory-Weiss tear). 
  • Peptic ulcer disease is possible but the history of preceding vomiting is typical and the shortness of breath is again peptic ulcer disease. 

27

A 76 year old man with a history of smoking has a 2 hour history of acute onset of epigastric and chest pain. His abdomen is non-tender and his pulse rate is 100 bpm. What is the most likely diagnosis? 

A Adenocarcinoma
B Chronic intestinal ischaemia
C Diffuse oesophageal spasm
D Gastro-oesophageal reflux disease
E Laceration (traumatic)
F Myocardial infarction
G Neuroendocrine tumour (‘carcinoid type’)
H Peptic ulcer
I Pharyngeal pouch

 

F - MI

  • Surgeons must be aware of medical conditions that can mimic surgical pathology. 
  • Epigastric and chest pain may be due to:
    • peptic ulcer disease 
    • intestinal ischaemia 
    • shortness of the history 
    • absence of abdominal signs make these less likely and IHD more so
  • All such patients should have an ECG and the interpretation should be documented in the notes. 

28

A 74 year old man with months of progressive dysphagia, weight loss of 4kg and anorexia. What is the most likely diagnosis?

A Adenocarcinoma
B Chronic intestinal ischaemia
C Diffuse oesophageal spasm
D Gastro-oesophageal reflux disease
E Laceration (traumatic)
F Myocardial infarction
G Neuroendocrine tumour (‘carcinoid type’)
H Peptic ulcer
I Pharyngeal pouch

A - Adenocarcinoma 

  • Weight loss and anorexia may be features of chronic intestinal ischaemia or peptic ulcer disease but the presence of dysphagia makes a tumour of the esophagus most likely. 
  • Carcinoid tumours are rarely a cause for the symptoms and adenocarcinoma is the most likely diagnosis. 

29

A 38 year old man who smokes 10 cigarettes/day has retrosternal burning pain after meals especially when lying down. He has some pain on swallowing with a sensation of food becoming 'stuck' in his throat. 

A Adenocarcinoma
B Chronic intestinal ischaemia
C Diffuse oesophageal spasm
D Gastro-oesophageal reflux disease
E Laceration (traumatic)
F Myocardial infarction
G Neuroendocrine tumour (‘carcinoid type’)
H Peptic ulcer
I Pharyngeal pouch

D - GERD

  • Adenocarcinoma of the esophagus, GERD, diffuse spasm and pharyngeal pouch may all present with problems with with swallowing. 
  • The burning pain on lying are much more suggestive of the presence of reflux. 
  • Spasms may be extremely difficult to differentiate from GERD and may present similar symptoms but simply on the basis of frequency - GERD is the more likely diagnosis. 

30

A 52 year old woman with 48 hours of epigastric and right sided abdominal pain, no jaundice, temperation of 37.8, a pulse of 100 - WBC - 14.7. What is the most likely diagnosis? 

A Abdominal aortic aneurysm (leaking)
B Acute appendicitis
C Acute cholecystitis
D Acute mesenteric ischaemia
E Acute pancreatitis
F Acute sigmoid diverticulitis
G Acute urinary retention
H Biliary colic
I Renal colic

 

C - Acute Cholecystitis 

  • The pain is associated with clear features of an inflammatory origin sosimple biliary colic, renal colic (without superadded infection), and leaking abdominal aortic aneurysm are all less likely.
  • The origin in the epigastrium makes appendicitis less likely and the presence of pain on the right makes pancreatitis similarly less likely leaving acute cholecystitis as the most likely cause.
  • The absence of jaundice simply means there is no cholangitis or secondary bile duct swelling or compression (Mirizzi syndrome).
     

31

A 72 year old man with 2h of severe central and left sided abdominal pain radiating to the left flank and back. He is feeling faint. He has generalised mild abdominal tenderness but no palpable masses. His pulse rate is 92 bpm, blood pressure is 116/80 mmHg. What is the most likely diagnosis? 

A Abdominal aortic aneurysm (leaking)
B Acute appendicitis
C Acute cholecystitis
D Acute mesenteric ischaemia
E Acute pancreatitis
F Acute sigmoid diverticulitis
G Acute urinary retention
H Biliary colic
I Renal colic

A - Abdominal aortic aneurysm (leaking) 

  • The combination of short-lived severe pain and haemodynamic upset (he is almost certainly hypotensive for his age and mildly tachycardic) suggests a non-inflammatory cause. 
  • Biliary or renal colic may be severe bu the relative hypotension is uncharacteristic. 
  • Acute mesenteric ischaemia typically causes severe pain but often gives rise to no abdominal signs
  • The lack of a palpable, pulsatile mass should never be taken as evidence agaisnt an AAA and the age and gender of the patient are typicaly of the diagnosis. 

32

A 47 year woman with 3 days of increasing left lower abdominal pain, mild dysuria and left iliac fossa and left flank tenderness presents. Her temperature is 37.7, pulse of 82, blood pressure of 135/76 mmHg. The urine is positive for blood and protein and negative for nitrites. What is the most likely diagnosis? 

A Abdominal aortic aneurysm (leaking)
B Acute appendicitis
C Acute cholecystitis
D Acute mesenteric ischaemia
E Acute pancreatitis
F Acute sigmoid diverticulitis
G Acute urinary retention
H Biliary colic
I Renal colic

F - Acute sigmoid diverticulitis 

  • The differential lies between left renal colic, sigmoid diverticulitis, and urinary tract infection.
  • The duration and onset all point strongly to diverticulitis.
  • The presence of blood and protein in the urine without the presence of nitrites is against urinary infection and can be explained by inflammation of the dome of the bladder by an adjacent loop of inflamed sigmoid colon.

33

A 52 year old man presents with 12 hours of intermittent colicky right sided abdominal pain, nausea and retching. Temperature is 37.4, pulse 82 and blood pressure 135/85. What is the most likely diagnosis? 

A Abdominal aortic aneurysm (leaking)
B Acute appendicitis
C Acute cholecystitis
D Acute mesenteric ischaemia
E Acute pancreatitis
F Acute sigmoid diverticulitis
G Acute urinary retention
H Biliary colic
I Renal colic

H - Biliary colic 

  • The short history and colicky nature of the pain makes an inflammatory process such as acute appendicitis less likely although still possible. 
  • The nausea and retching favour a biliary or upper GI origin to the pain rather than renal colic and although there is a mild tachycardia, this is most likely to be due to pain rather than inflammation making biliary colic the most likely diagnosis

34

An 81 year old man with some cognitive impairment is reported by his carers to have seemed to have 6h of progressively increasing lower abdominal, left iliac fossa and suprapubic pain. There is mild lower abdominal tenderness but no obvious mass. His temperature is 37.2, pulse is 88bpm and blood pressure is 155/85. What is the most likely diagnosis? 

A Abdominal aortic aneurysm (leaking)
B Acute appendicitis
C Acute cholecystitis
D Acute mesenteric ischaemia
E Acute pancreatitis
F Acute sigmoid diverticulitis
G Acute urinary retention
H Biliary colic
I Renal colic

G - Acute urinary retention 

  • Lower abdominal pain can be difficult to differentiate, especially in the elderly. 
  • The absence of fever is against the presence of an infective or inflammatory case but one should be cautious in the elderly as the temperature may be kepy artificially low. 
  • The mild hypertension may be normal for him but is typically of distress relate to autonomic derived pain as is the tachycardia. 
  • A diagnosis of sigmoid diverticulitis must be considered but a trial catheterization should be undertaken first even if the bladder is not obviously distended as urinary retention is a common cause for these symptoms in this age and congitive state.